As Comair Flight 5191 accelerated down an unlit runway into the predawn darkness at Blue Grass Airport in Lexington, Ky., last August 27, the captain–the nonflying pilot–called out “V one, rotate” followed by “whoa” and then an expletive.
The Bombardier CRJ100 ran off the end of Runway 26 while still on the ground, crossed a berm past the runway end and became airborne before hitting some trees and bursting into flame. Of the 47 passengers and three crewmembers on board, only the first officer–the flying pilot–survived. He sustained serious injuries.
The airplane, which had been cleared for Runway 22 by the lone controller in the tower cab, taxied onto Runway 26 instead. At 7,002 feet, Runway 22 was twice as long as Runway 26. But to reach the threshold of Runway 22, the accident crew had to taxi across the end of Runway 26.
The NTSB opened the public docket last month and released a series of factual reports with no analysis. Included were investigative group reports; interviews, including with air traffic controllers; cockpit voice recorder transcripts and ATC communications; and other documents from the investigation. The Safety Board will add material to the docket as it becomes available. Analysis of the accident, along with conclusions and determination of probable cause, will come when the final report on the investigation is completed.
According to the van driver who took the crew from the hotel to the airport that morning, the accident crewmembers were standing and waiting in the lobby with no food or beverages when he arrived to take them to the airport. He said they did not appear tired and he saw no yawning or stretching.
The captain for another airline watched the crew as they went through security. He said both pilots had hats and coffee mugs and nothing seemed out of place. He did not see either of them yawning.
A customer service agent working in operations said that when they checked in at Comair at about 0515 they did not appear to be sleepy or fatigued. The lead customer service agent described the crew as making casual conversation in operations and described them as “very professional.”
However, when they went to the ramp area where three Comair CRJs were parked they initially boarded the wrong airplane and powered it up using the APU. Ramp personnel noticed that they were on the wrong airplane and entered the airplane cabin to tell the crew of their mistake. At about 0520, the accident crew checked their paperwork, gathered their bags and proceeded to the correct airplane.
At 0600 the sun had yet to rise and night conditions existed. There was no rain, and visibility was eight miles. Floodlights at the terminal illuminated the ramp area and taxiway lights were lit on Taxiway A. The runway lights on Runway 22 were on medium intensity. Runway 26 lights were not illuminated and the runway was notam’d closed except during daytime operations.
The normal taxi route to Runway 22 or Runway 26 used Taxiway A. The taxi clearance as stated by ATC allowed the crew to taxi across Runway 26 en route to the assigned takeoff runway.
There were no designated “hotspots” on the ramp area or along the taxi route. Areas of concern for the crew along the taxi route would have been the crossing of Runway 26 and the fact that a portion of the original Taxiway A between Runway 26 and Runway 22 was under construction. Therefore, Taxiway A was altered beyond Runway 26. The accident crew was not informed of the change to Taxiway A by the controller, the ATIS or the company flight paperwork.
The captain taxied the airplane while the first officer prepared the cockpit for departure and performed his required checklists. The CRJ100 was taxied to a position that was the hold-short point for Runway 26 and stopped at 0604:33. It remained at the hold-short point for 46 seconds while the first officer completed his before-takeoff checklist.
He then called for takeoff clearance and ATC cleared the flight for takeoff. Neither the first officer nor the tower controller stated the runway during the request for and clearance for takeoff. The captain read back “runway heading, cleared for takeoff, one ninety one” and confirmed to the first officer “and line-up check.”
The captain taxied onto Runway 26 and aligned the aircraft for takeoff. At about 0606, the captain handed controls over to the first officer, who pushed the thrust levers toward the takeoff power setting and asked the captain to adjust the engine power for takeoff. The cockpit area microphone recorded a sound similar to increase in engine rpm. As the takeoff began, the first officer commented, “Dat is weird with no lights.” The captain responded, “Yeah.”
The ATIS information indicated that the departure runway was Runway 22 and the controller cleared the flight to taxi to Runway 22. The flight data recorder (FDR) indicated that the accident pilots had their heading bug set to 227 degrees, which corresponded closely with the 226-degree magnetic heading for Runway 22 as depicted on their Jeppesen airport chart. The course selector was set to 226 degrees.
The NTSB said post-accident interviews indicated that after an aircraft had been taxied into takeoff position on the runway, most Comair pilots would press on the heading knob to sync the aircraft heading with the heading bug. Pilots reported that this sync of the heading bug and runway heading would normally cause only a minor movement of the bug.
The FDR on the accident airplane indicated the heading bug remained on the 227-degree setting during the takeoff, indicating that the accident crew did not push the HDG knob before takeoff. If they had pushed the HDG knob when in takeoff position, the heading bug would have moved about 40 degrees to the right on the HDG and the crew might have noticed the movement.